SHIFTING PROPORTIONS OF GASTRIC ADENOCARCINOMAS

Objectives: To substantiate reports of increasing proportions of gastr ic adenocarcinoma of diffuse histologic type and in the proximal porti on of the stomach, to better understand the prognostic features that g overn survival, and to determine whether alterations of operative stra tegy might improve the surgical results. Design: Retrospective analysi s of 289 consecutive patients with gastric adenocarcinoma operated on by general surgeons over a 26-year period. Records were reviewed for l ocation, histologic type, resection, operative mortality, lymph node s tatus, and outcome. Setting: The Section of Surgical Oncology, the New England Deaconess Hospital, Boston, Mass. Main Outcome Measures: Surv ival rate, length of life of the patients who died, and operative mort ality. Results: A marked and significant shift of gastric adenocarcino ma to a proximal location (54% between 1985 and 1990) occurred over 26 years (P=.0075) with a significant stage improvement at presentation (P=.0235). Percentages of cancers that were of the diffuse, poorly dif ferentiated histologic type increased to 48%. More curative operations were performed in the last period (61%), and this upward trend from 3 7% was significant. Proximal gastric cancers had a poorer prognosis wi th more operative deaths, more lymph node metastases, and worse surviv al rates than distal cancers. Poor survival rates occurred even when c omparing patients with negative lymph nodes or favorable histologic fe atures with patients with similar distal cancers. Conclusions: Despite significant increases in the proportion of proximal cancers, survival rates have improved only slightly. Nodal status plays a less prognost ic role than does location or histologic type but does provide prognos tic information for individual locations. Survival rates for diffuse h istologic cancer were consistently worse than those for intestinal his tologic cancer, which emphasizes the underlying disease biology contro lling outcome. Radical lymphadenectomy for gastric adenocarcinoma woul d not improve surgical outcome in the United States.